How Tightened Controls on Prescribing for Medicare Part D Patients May Affect Health Care Providers-Part 1

Wednesday, June 4, 2014
By Lance O. Leider, J.D., The Health Law Firm

On June 1, 2015, doctors and other health care providers will be under tighter restrictions when prescribing to Medicare Part D patients. A final rule released by the Centers for Medicare and Medicaid Services on May 19, 2014, requires health care providers to enroll in the Medicare program, or have a valid opt-out affidavit on file, for prescriptions to be covered under Part D. This requirement closes a loophole that previously allowed some practitioners, such as massage therapists, athletic trainers and dental hygienists to prescribe drugs.

Most health care providers are already enrolled in Medicare. Those most affected will be dentists and Veterans Affairs physicians who currently provide services not covered by Medicare but have patients whose prescriptions are paid by Medicare.

Details of the New Rule.

Providers have until the beginning of June 2015 to either enroll in Medicare or formally opt out, allowing them to continue prescribing. When a health care provider enrolls, the government verifies his or her professional license and credentials, and asks about his or her criminal histories.

The final rule expands rewards and incentive programs focusing on encouraging participation in activities that promote improved health, efficient use of health-care resources and preventing injuries and illness, and also broadens the release of privacy-protected data.

The proposed rule issued in January 2014 contained a variety of controversial changes to the Medicare Part D program, including changes to criteria for protected drug classes, preferred pharmacies and the medication therapy management programs.  After an uproar from Congress and the public, CMS backed down on these provisions.

In addition, the rule will expand the release of unencrypted, prescriber, insurer and pharmacy identifiers listed in prescription drug records. This will provide easier access to prescription drug data for researchers.

Click here to read the 487-page final rule from CMS

Widespread Fraud in Medicare Part D Prescriptions.

The need for this new rule allegedly stemmed from a series of articles appearing on NPR exploring CMS’s lax oversight of the Medicare Part D program. This enabled some health care providers to be able to prescribe massive quantities of inappropriate or risky medications, waste billions on expensive drugs and expose the program to rampant fraud. The newly released rule will assist CMS in cracking down on doctors and other health care providers that are reckless or abusive in prescribing drugs to Medicare patients.

According to NPR, a report by the Office of the Inspector General (OIG) found that 108 physicians scrutinized ordered an average of 71 prescriptions per Medicare beneficiary, that is five times the national average.

Click here to read more from NPR.

Saving Money.

This final rule gives CMS new tools and powers to combat fraud and abuse in the Medicare Part D program. CMS claims that once implemented the new rule will save the federal government $1.6 billion over the next decade.

Previously, CMS had no authority to take action against health care providers accused of fraud and abuse in the Medicare Part D program. However, with the new rule, when a health care provider is found to be violating the rules there could be some serious consequences.

Check this blog regularly for part two to find out what those consequences are.

Contact Attorneys Experienced in Defending Against Action to Exclude an Individual or Business from the Medicare Program.

The attorneys of The Health Law Firm have experience in dealing with RAC audits, ZPIC audits, pharmacy audits, DOH investigations, DEA investigations, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), and defending against action to exclude an individual or business entity from the Medicare Program, in administrative hearings on this type of action, in submitting applications requesting reinstatement to the Medicare Program after exclusion, and removal from the List of Excluded Individuals and Entities (LEIE).

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at


Will this final rule affect you? If so, how? Please leave any thoughtful comments below.


Demko, Paul. "Docs Will Need to Enroll in Medicare if They Want to Prescribe Part D Drugs." Modern Healthcare. (May 19, 2014). From:

Ornstein, Charles. "Following Abuse, Medicare Tightens Reins on its Drug Program." National Public Radio. (May 20, 2014). From:

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area.  The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone:  (407) 331-6620.

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"The Health Law Firm" is a registered fictitious business name of George F. Indest III, P.A. - The Health Law Firm, a Florida professional service corporation, since 1999.
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